'Addiction: a Disorder of Choice' is a very different
book, that is highly scholarly in its style, grounded in clear research
and has a fascinating attention to detail. More psychological in his
approach, Heyman offers us insight into the mindset of
'addiction' , and therefore some kind of strategy for a
solution is possible. His scope is wide and historically fascinating. At
173 pages of text, in seven chapters, the book is succinct, but with
several pages of notes, and a respectable reference list of 17 pages.

Starting with a critical view of the 1914 Harrison Narcotics Tax
Act and past responses to addiction, the book traces features of illicit
drug use prior to the first legal prohibitions. It is essential to do
this to come to a better understanding of addiction as addictive drugs
promote chaotic and unhappy social relations, and medical problems,
which have led to social policies more notable for their costs rather
than their effectiveness. It was over a century ago, in the 19th and
early 20th centuries, that Americans tended to medicate themselves
rather than seek out professional help. Such medicines included alcohol,
opiates, and cocaine, all used as self treatments. Such potions were
unregulated and commonly thought to be the best option. It was during
this period that America was described as 'a dope fiend's
paradise' , (Brecher, 1972). Interestingly, the differences in self
administration techniques were accompanied by important demographic
differences. For instance, the opium drinkers and eaters in the
public's eye were refined, simply taking a sophisticated
indulgence. Laudanum drinking was an aristocratic vice more common among
the educated and wealthy. However, opium smokers were considered social
outsiders, and not mainstream Americans, usually Chinese immigrants who
were labourers. They came to be known as 'yellow peril' , far
from being fallen aristocrats, they would have been depicted as being
evil. Finally, the heroin sniffers were usually underemployed young men
who would quit school early, had a history of delinquency and liked to
go to vaudeville shows. So therefore, physicians attended opium eaters;
law enforcement officials dealt with opium smokers and heroin sniffers.
These distinctions were institutionalised in the 1914 Harrison Act. The
focus then shifts to the toll on contemporary American society, with
various modes of data outlining the fact that between 2001 and 2002
almost 14% of all Americans who were 18 years old and older had a
history of addiction. We then learn that addiction is framed as a
chronic, relapsing, brain disease that is a chronic illness that should
be classified with diseases like asthma and diabetes, according to The
National Institute on Drug Abuse, (N.I.D.A.). However, the fact that
treatment often teaches, offers advice, arranges contingencies, and
conveys techniques for improving social relations and generally taking
advantage of non-drug alternatives fits neither a medical model nor a
penal model of rehabilitation. Such dynamics are simply the most logical
treatment approach if addiction is not a compulsive disorder but one in
which voluntary behaviour is self-destructive.

Substance dependence as opposed to addiction is then explored. It
is said of substance dependence that it is a cluster of cognitive,
behavioural, and physiological symptoms indicating that the individual
continues the use of a certain substances, while encountering problems,
resulting in tolerance and compulsive drug-taking behaviour. Addiction
is also defined in the Oxford English Dictionary as being compulsive, so
we can be sure that researchers are speaking of the same phenomenon in
both instances. Having ascertained this, the author includes some very
useful graphs used to illustrate various fascinating statistics. For
example, to illustrate the chances of being diagnosed with a psychiatric
disorder, or perhaps the influence of neighbourhood on drug use itself,
and even drug use, and drug disorders as a function of income.

Moving on, we can read of the subjective experience of drug-taking,
as Heyman includes several first person accounts of positive initial
drug experiences,

These vignettes continue, covering negative drug experiences,
reflections on addiction, withdrawal, quitting and not quitting. They
convey the spectrum of drug experiences to the reader, which is useful
for anchoring the text to a sense of everyday reality.

The prognosis for addicts is then questioned, although initially
the picture looks bleak with addiction researchers claiming, 'that
"cure" is an unrealistic hope, and that addictive treatments
should be considered in the category with other disorders that require
long-term or lifelong treatment', (p.65). This gloomy vision has
empirical support, with, 'the claim that addiction is a chronic
relapsing disorder can be backed up by more than a hundred years of
research', (p.66).

However, the author then proceeds to examine the various surveys
concerning psychiatric health and treatment. Firstly, there is the
Epidemiologic Catchment Area study, which started in 1980 and took four
years to complete, with 19,000 subjects participating. The data showed
that at approximately age 24, more than half of the former
'addicts' , no longer reported one symptom. By the age of 37,
75% who were once drug dependant no longer reported one symptom.

The next surveys are 'The National Co-morbidity Survey',
(N.C.S.), 1990-92 and replication 2001-02, with about 8,100 and 9,300
subjects. This study also confirmed that most lifetime addicts were in
fact in remission. Although, addicts in treatment were more likely to
relapse, indicating that clinic addicts could be using more addictive
drugs. A more likely explanation though, is that addicts in treatment
are much more likely to suffer from additional psychiatric disorders
than those not in treatment. So, the author emphasises that in fact
clincs can help, and that recovery, not relapse was the norm, hovering
at around 80 to 90% for certain middle class professionals.

Genetics are then focused upon, with the author explaining that
most of the research has focused on alcoholics, as it is easier to
conduct multigenerational research on legal drugs than illegal ones. Dr.
Robert Cloninger's work in Sweden is reviewed, showing that the
biological father's drinking pattern was normally a good predictor
of alcohol abuse in their sons, even if they were adopted. Supporting
this argument, a US government public health bulletin reported in June
2008, 'Drug addiction is a brain disease because the abuse of drugs
leads to changes in the structure and function of the brain' ,
(p.95). A historical overview of 17th-century understandings of
addiction is then given, which also relates to this argument. The focus
then reverts to the present day, looking out drug users who were doctors
or aeroplane pilots. If they tested positive for drugs they would lose
their jobs, and professional careers, so there were serious
consequences. This theme of using incentives, even modest ones could
persuade addicts to quit using drugs, and has been used in the form of
vouchers and prosocial lifestyles. It was found that just as heavy drug
use initiates a downward spiral of increasingly negative consequences
and decreasing options, healthy alternative activities can set in motion
an upward spiral of increasingly positive consequences and increasing
options.

The psychology of 'choice' is then viewed, looking at the
concept of 'local choices' and 'global choices'.
Local, meaning choosing the option that has currently the higher
short-term value. In global choice, however, the best choice is the
total collection or sequence of items that would have the higher value.
The conclusion being, that addicts normally choose local choices, and
not global ones. As the author phrases it, a person who framed his or
her choices globally, would never use drugs, as it would affect the
quality of their overall lifestyle. A heavy drug user who would switch
to a global choice perspective will stop using drugs; however, it would
be difficult to maintain this new perspective, as the rewards associated
with this perspective accrue rather slowly. At the beginning of
abstinence the value of the non-drug day is less than the value of the
most recent drug days, from a local perspective. So the value of
lifestyle, and a nondrug alternative, is of key importance.

'Just say dopamine', was a title for an article in
Science News during the height of the recent war on drugs. However,
Heyman correctly comments though that aversive events increase dopamine
levels too. He states that with rats, 'a tale pinch illicits
avoidance, and the release of dopamine in the nucleus accumbens' ,
(p.143). Marriage is relevant though; as is the case with schizophrenia,
there are relatively few current addicts who marry according to the data
on marital status. Cultural traditions and social institutions offer a
wealth of information and proscriptions to set limits on behaviour,
through social teachings. Social roles, lifestyles, and even religious
values set limits on appetites and the maintenance of prudential rules.
Such prudential rules are reinforced by the benefits that come with
global equilibrium, and are reinforced on a moment to moment level by
their social implications. So, lost time in the late teens and early
twenties due to a regular regime of intoxication, can be unrecoverable
warns Heyman. Research on drug use implies that these individuals
repeatedly make choices that are not in their long term interest, thus
this suboptimal thinking is considered by the author to be a
'disorder of choice'.

Although not as radical as Schaler's work, this book clearly
achieves its goal of delivering a psychological theory with which to
combat addiction. I consider this book to be well researched, and
written in a highbrow scholarly, refined, academic style. I would
recommend this book to academics, as well others with an interest in
psychology. For existential practitioners, despite seemingly orthodox,
this book would definitely be of use, as it provides an eloquent
discourse challenging the chronic, disease model of addiction, and
offering a functional psychological explanation that would be applicable
in certain cases, informing their practice for the better. In presenting
a theory based on the concept of choice, Heyman is contributing to the
existential psychotherapeutic literature on addiction, for those
therapists on the quest for a solution.

Warner,J. (1994). Resolv'd to Drink No More': Addiction
as a Preindustrial Construct. Journal of Studies on Alcohol. Vol.55.
pp.685-691.

... I found complete satisfaction.... at first I felt
exhilarated...
(p.46).
'....and then came a surge of astonishing pleasure, in which I
could think of nothing but how oddly benign the drug felt.....'
(p.47).
... from the very first hit some drugs makes some people feel
fantastic... when it happens to you, you don't forget it. And you
want more. Once is never enough
(p.47).